=====================================================
General NPI Number Information
=====================================================
NPI Number | 1295562536
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | FOUR COUNTY COMPREHENSIVE MENTAL HEALTH CENTER INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/19/2024
-----------------------------------------------------
Last Update Date | 09/19/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1000 N BROADWAY
-----------------------------------------------------
City | PERU
-----------------------------------------------------
State | IN
-----------------------------------------------------
Zip | 46970-1070
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 574-722-5151
-----------------------------------------------------
Fax | 574-739-1414
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2355 S BUSINESS 31
-----------------------------------------------------
City | PERU
-----------------------------------------------------
State | IN
-----------------------------------------------------
Zip | 46970-8985
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 574-722-5151
-----------------------------------------------------
Fax | 574-739-1414
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CEO
-----------------------------------------------------
Name | CARRIE ANN CADWELL
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 574-721-3983
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QR0400X
-----------------------------------------------------
Taxonomy Name | Rehabilitation Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 261QM0801X
-----------------------------------------------------
Taxonomy Name | Mental Health Clinic/Center (Including Community Mental Health Center)
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------